course materials

1. Factors Influencing the Realization of Quality Improvement in Healthcare
Discussion
Factors Influencing the Realization of Quality Improvement in Healthcare Discussion ON
Factors Influencing the Realization of Quality Improvement in Healthcare DiscussionRead
Chapter 10 answers the questions in APA Format, Times New Roman 12 font1. In the last
century, what historical, social, political, and economic trends and issues have influenced
today’s health-care system?2. What is the purpose and process of evaluating the three
aspects of health care: structure, process, and outcome?3. How does technology improve
patient outcomes and the health-care system?4. How can you intervene to improve quality
of care and safety within the health-care system and at the bedside?2. Select one nonprofit
organization or one government agencies that influences and advocates for quality
improvement in the health-care system. Explore the Web site for your selected
organization/agency and answer the following questions: •What does the
organization/agency do that s the hallmarks of quality? •What have been the results of
their efforts for patients, facilities, the health-care delivery system, or the nursing
profession? •How has the organization/agency affected facilities where you are practicing
and your own professional practice?chapter_10_issues_of_qUnformatted Attachment
Previewchapter 10 Issues of Quality and Safety QI at the Organizational and Unit Levels
Strategic Planning Structured Care Methodologies Critical Pathways Aspects of Health Care
to Evaluate Structure Process Outcome Risk Management The Nursing Shortage and Patient
Safety Factors Contributing to the Nursing Shortage Safety in the U.S. Health-Care System
Types of Errors Error Identification and Reporting Developing a Culture of Safety
Organizations, Agencies, and Initiatives ing Quality and Safety in the Health-Care System
Government Agencies Health-Care Provider Professional Organizations Nonprofit
Organizations and Foundations Quality Organizations Integrating Initiatives and Evidenced-
Based Practices Into Patient Care Influence of Nursing Conclusion use good judgment when
making decisions about care. As nurses we need to understand that we work within a
system, and whenever there is a breakdown somewhere within the system, the risk for
error increases. This chapter discusses quality and safety in health care, presents reasons
for errors, and offers ways nurses can help to create a culture of safety. Historical Trends
and Issues Many forces drive the rapidly changing health-care delivery system (Baldwin,
Conger, Maycock, & Abegglen, 2002; Davis, 2001; Elwood, 2007; Ervin, Bickes, & Schim,
2006; Menix, 2000; Milton, 2011). In this time of global health-care reform, regulation at the

2. global, national, state, and local levels has taken on a new significance (Milton, 147 148 unit
3 ? Career Considerations 2011). The impetus to decrease costs and improve outcomes
influences the current movement toward improved quality and safety. These forces include
economics, societal demographics and diversity, regulation and legislation, technology,
health- care delivery and practice, and environment and globalization. Economics. Many
economic trends and issues affect the U.S health-care delivery system. Busi- nesses,
government, and the media criticize the cost of health care within the United States when
compared with that of other developed nations ( Jackson, 2006; Kersbergen, 2000; Milton,
2011). The costs of research and the costs to develop new treatments and technology
continue to rise. Edu- cated consumers expect safe, quality care with asso- ciated
satisfaction and positive health outcomes. Nurses need to be prepared to consumers with
a thorough knowledge of quality, account- ability, and cost-effectiveness (AACN, 2008,
2012). This means that they must have the knowledge to educate patients regarding the
technology used in their treatments and explain the rationale behind the treatment
selection. While initial expenses may increase, improvements in quality and safety will
reduce costs in the long term (Aiken et. al., 2012; Cronenwett et al, 2007; Institute of Medi-
cine [IOM], 2003a; Weiss, Yakusheva, & Bobay, 2011). Societal demographics and diversity.
Increased numbers of racial and ethnic groups influence health-care delivery (Billings &
Halsted, 2011; Davis, 2010; Factors Influencing the Realization of Quality Improvement in
Healthcare DiscussionElwood 2007; Health and Human Services [HHS], 2011; Heller, Oros,
& Durney- Crowley, 2000; World Health Organization, 2009). Increased numbers of the
elderly, longer life expec- tancy, and improvements in technology result in an emphasis on
specialized geriatric care. Both the elderly and ethnic minorities are at-risk popula- tions
who suffer disadvantages in access to care, payment for care, and quality of care (Affordable
Care Act, 2010; Anderson, Scrimshaw, Fullilove, Fielding, & Normand, 2003). It is hoped that
the passage of the Affordable Care Act (ACA) will minimize these disparities as more of
these indi- viduals will have access to health-care services (Davis, 2010). Regulation and
legislation. The diverse interests of consumers, insurance companies, government, and
regulation affect health-care legislation. For health-care leaders and providers of care,
unprecedented challenges continue despite the attention that quality and safety have
received during the evolution of the existing health-care system. The ACA now provides
health care to individuals who previously lacked coverage. This access to care will increase
the numbers of individuals who will need providers as well as force changes in regulation
and cost management. Technology.The use of technology and the incor- poration of the
electronic health record are pro- jected to decrease costs and improve clinical outcomes,
quality, and safety (IOM, 2003a; Poon et al., 2010). Nursing practice must adjust to these
health-care delivery trends with the inclusion of concepts in interprofessional collaboration,
patient- focused systems, and information literacy (Booth, 2006; Sargeant, Loney, &
Murphy, 2008). Addi- tionally, nurses must utilize technology and infor- matics to
incorporate evidenced-based practices for improved quality and safety in the health-care
delivery system (Hunter, 2011). Technology also produces advancements in disease
treatments, especially in the areas of genet- ics and genomics, and all professionals must
inte- grate these advancements into practice (Calzone, Cashion, Feetham, Jenkins, Prows,

3. Williams, & Wung, 2010; Lea, Skirton, Read, & Williams, 2011).The current advances in
genetics and genom- ics continue to allow the redesign of treatments for a variety of genetic
disorders, quality improvement (QI), and outcomes in clinical practice often related to
pharmacotherapeutics Factors Influencing the Realization of Quality Improvement in
Healthcare Discussion(Trossman, 2006; Lea, Skirton, Read, & Williams, 2011). Health-care
delivery and practice. Health-care professionals should be prepared to provide safe, quality
care in all settings, including acute care and community settings. Nurses and other health-
care professionals need the knowledge, skills, attitudes, and competencies to function in a
variety of set- tings and the ability to the needs of the increasingly diverse population
(Anderson et al., 2003; Ervin, Bickes, & Schim, 2006; Heller, Oros, & Durney-Crowley, 2000).
The integration of evidenced-based practice serves to improve quality and safety for
patients, and improves collaboration and interprofessional teamwork (IOM, 2003a; O’Neill,
1998). Both the IOM (2003a) and the Pew Health Professions Commission (PEW, 1998)
identified the need for the health-care delivery system and its profession- als to improve
collaboration and to work in an interprofessional team to improve quality and safety.
Environment and globalization. The emergence of a global economy, the ease of travel, and
advances in communication technology affect the move- ment of people, money, and disease
(Heller, Oros, & DurneyCrowley, 2000; Kirk, 2002). Global warming and climate change
have been linked to the emergence of new drug-resistant organisms and an increase in
vector-borne and waterborne disease as warmer temperatures promote changes in organ-
ism structure and increase the growth rate of bactable 10-1 Historical Timeline teria.
Increased ease of travel allows for migration of affected populations. Safe, quality health
care will need to confront the challenges of increasing multiculturalism, potential for
pandemic, and the effect of climate change and pollution on health. In addition, many
health-care professionals, government agencies, and ing organizations have contributed to
the evolution of quality and safety within the health-care system. The Histori- cal Timeline
(Table 10-1) highlights significant organizations and initiatives of importance to quality and
safety. chapter 10 ? Issues of Quality and Safety 149 1896 1906 1918 1930s 1945 1951
1955 1966 1970 1979 1986 1989 1990 1990 1991 1996 1996 1998 1999 2001 2001 2001
2001 2003 2003 2003 2004 2004 2005 2006 2014 Nurses Associated Alumnae of the
United States and Canada formed, later called the American Nurses Association (ANA)
Factors Influencing the Realization of Quality Improvement in Healthcare DiscussionFood
and Drug Act signed, which began the regulation of food and drugs to protect consumers
American College of Surgeons founded, which initiated minimum standards for hospitals
and on-site hospital inspections for adherence to standards Employers began offering
health benefits, and the first commercial insurance companies arose Quality management
principles developed by Edward Deming were applied successfully to industries such as
manufacturing, government, and health care Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) founded; currently referred to as The Joint Commission
(JC) Social Security Act passed; hospitals that had volunteered for accreditation by JCAHO
were approved for participation in Medicare and Medicaid Quality of health-care services
defined in the literature IOM established as a nonprofit adviser to the nation to improve
health in the national academies National Committee on Quality Assurance (NCQA)

4. established National Center of Nursing Research founded at the National Institutes of Health
(NIH) Agency for Healthcare Research and Quality (AHRQ) established NCQA began
accrediting managed care organizations by using data from Health Plan Employer Data and
Information Set (HEDIS) Institute of Healthcare Improvement (IHI) founded Nursing’s
Agenda for Health Care Reform published by the ANA National Patient Safety Foundation
(NPSF) founded; JC established Sentinel Event Policies IOM launched three-part initiative to
study health-care system quality IOM National Roundtable on Health Care Quality released
Consensus Statement IOM published To Err is Human: Building a Safer Health System IOM
published Crossing the Quality Chasm: A New Health System for the 21st Century IOM
published Envisioning the National Health Care Quality Report ANA’s National Database for
Nursing Quality Indicators (NDNQI) demonstrated the positive impact of the appropriate
mix of nursing staff on patient outcomes JC mandated hospital-wide patient safety
standards IOM published Priority Areas for National Action: Transforming Health Care
Quality, which established priority areas for national action to improve quality of care and
outcomes (Box 10-1) JC established first set of National Patient Safety Goals (NPSG) IOM
published Health Professions Education: A Bridge to Quality IOM published Keeping
Patients Safe: Transforming the Work Environment of Nurses IOM published Patient Safety:
Achieving a New Standard of Care ANA updated its Health Care Agenda, urging system
reform IOM published Preventing Medication Errors: Quality Chasm Series JC updated
National Patient Safety Goals 150 unit 3 ? Career Considerations box 10-1 Institute of
Medicine Priority Areas (IOM, 2003b) and strategy for health system reform (Box 10-2).
Two in particular, To Err is Human: Building a Safer Health System (IOM, 2000) and
Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), provide
a framework upon which the 21st-century health-care system is being built. In 2011 the
IOM released a report on The Future of Nursing: Leading Change, Advancing Health (IOM,
2011). Factors Influencing the Realization of Quality Improvement in Healthcare
DiscussionThis report describes the changes needed in nursing practice and nursing
education to promote nursing’s role in the new era of health-care delivery. To Err is Human,
discussed later in this chapter, quantified unnecessary death in the U.S. health- care system
and placed emphasis on system failures as the foundation for errors and mistakes. Accord-
ing to the report, it is the flawed systems in patient care that often leave the door open for
human error. The report made a series of eight recommendations in four areas (Box 10-3)
that aimed to decrease errors by at least 50% over 5 years. The goal of the box 10-2 IOM
Quality Reports (IOM, 2006) • Crossing the Quality Chasm: The IOM Quality Health Care
Initiative (1996) • To Err Is Human: Building a Safer Health System (2000) • Crossing the
Quality Chasm: A New Health System for the 21st Century (2001) • Envisioning the National
Health Care Quality Report (2001) • Priority Areas for National Action: Transforming Health
Care Quality (2003b) • Leadership by Example: Governmental Roles (2003) • Health
Professions Education: A Bridge to Quality (2003a) • Patient Safety: Achieving a New
Standard of Care (2003) • Keeping Patients Safe: Transforming the Work Environment for
Nurses (2004) • Academic Health Centers: Leading Change in the 21st Century (2004) •
Preventing Medication Errors: Quality Chasm Series (2006) box 10-3 Focus Areas of To Err
is Human Recommendations (IOM, 2000) • Enhance knowledge and leadership regarding

5. safety. • Identify and learn from errors. • Set performance standards and expectations for
safety. • Implement safety systems within health-care organizations. • • • • Asthma Cancer
screening Care coordination Children with special care needs • • • • • • Diabetes End-of-life
issues Frail elderly Health literacy Hypertension Immunizations • Ischemic heart disease •
Major depression • Nosocomial infections • Obesity • Pain control in advanced cancer •
Pregnancy and childbirth • Self-management • Severe, persistent mental illness • Stroke •
Tobacco dependence in adults The Institute of Medicine and the Committee on the Quality
of Health Care in America The Institute of Medicine (IOM) is a private, non- profit
organization chartered in 1970 by the U.S government. The IOM’s role is to provide
unbiased, expert health and scientific advice for the purpose of improving health. The result
of the IOM’s work s government policy making, the health- care system, health-care
professionals, and consum- ers (Box 10-1). In 1998 the IOM National Roundtable on Health
Care Quality released Statement on Quality of Care (Donaldson, 1998), which urged health-
care leaders to make urgent changes in the U.S. health-care system. The Roundtable reached
con- sensus in four areas regarding the U.S. health-care system: 1. Quality can be defined
and measured; 2. Quality problems are serious and extensive; 3. Current approaches to
quality improvement (QI) are inadequate; and 4. There is an urgent need for rapid change.
This IOM statement launched today’s movement to improve quality and safety for the 21st
century U.S. health-care system. In 1998 the IOM charged the Committee on the Quality of
Health Care in America to develop a strategy to improve health-care quality in the coming
decade (IOM, 2000). The Committee completed a systematic review and critique of lit-
erature that highlighted and quantified severe shortcomings in the heath-care system. Its
work led to the series of reports that serves as the foundation box 10-4 Ten Rules to Govern
Health-Care Reform for the 21st Century (IOM, 2001, p. 61) 1. Care is based on a continuous
healing relationship. 2. Factors Influencing the Realization of Quality Improvement in
Healthcare DiscussionCare is provided based on patient needs and values. 3. Patient is
source of control of care. 4. Knowledge is shared and free-flowing. 5. Decisions are
evidence-based. 6. Safety is a system property. 7. Transparency is necessary; secrecy is
harmful. 8. Anticipate patient needs. 9. Waste is continually decreased. 10. Cooperation is
needed between health-care providers. recommendations was “for the external environ-
ment to create sufficient pressure to make errors costly to health-care organizations and
providers, so they are compelled to take action to improve safety” (IOM, 2000, p. 4). The
recommendations sparked public interest in health-care quality and safety and caused
prompt responses by the govern- ment and national quality organizations. Crossing the
Quality Chasm addressed broad quality issues in the U.S. health-care system. The report
indicated that the health-care system is fun- damentally flawed with “gaps,” and it proposed
a system-wide strategy and action plans to redesign the health-care system. The report
stated that the gaps between actual care and highquality care could be attributed to four
key inter-related areas in the health-care system: the growing complexity of science and
technology, an increase in chronic conditions, a poorly organized delivery system of care,
and constraints on exploiting the revolution in information technology. With the
overarching goal of improving the health-care system by closing identifiable gaps, the
report made 13 recommenda- tions, some of which are in Box 10-4. Additionally, the report

6. addressed the importance of aligning and designing healthcare payer systems, profes-
sional education, and the health-care environment for quality enhancements, improved
outcomes in care, and use of best practices. The Future of Nursing: Leading Change, Advanc-
ing Health discusses the role of nursing in the 21st century.This document recognizes that
the nursing profession confronts many challenges in the chang- ing health-care system. It
identifies recommenda- tions for an “action-oriented blueprint for the future of nursing”
(RWJF, 2008, p. s-2). As a professional nurse, you have a responsibility to acknowledge the
complexity and deficits of the health-care system. In managing patient care, you must
continually consider the impact of the system on the care you provide and participate in the
quality and safety initiatives at the bedside, in your unit, and within your organization to
promote quality and safety within the system. Quality in the Health-Care System The IOM
defines quality as “the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current and
professional knowledge” (IOM, 2001, p. 232). This definition is used by U.S. organizations
and many international health-care organizations, and it is the basis for nursing
management of patient care. Box 10-5 elaborates on this definition by outlining six primary
aims of health care. Quality Improvement (QI) QI activities have been part of nursing care
since Florence Nightingale evaluated the care of soldiers during the Crimean War
(Nightingale & Barnum, 1992). To achieve quality health care, QI activities use
evidencebased methods for gathering data and achieving desired results. Before the 1980s,
health-care institutions focused on quality assurance (QA) rather than QI. QA outlined an
inspection process to guarantee that hospitals continued to follow minimum box 10-5 Six
Aims for Improving Quality in Health Care (IOM, 2001, p. 39). Health care should be: 1. Safe:
Avoiding injuries to patients from the care that is intended to help them 2. Effective:
Providing services based on scientific knowledge to all who could benefit and refraining
from providing services to those not likely to benefit (avoiding underuse and overuse) 3.
Patient-centered: Providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical decisions 4.
Timely: Reducing waits and sometimes harmful delays for those who receive and those who
give care 5. Efficient: Avoiding waste, in particular that of equipment, supplies, ideas, and
energy 6. Equitable: Providing care that does not vary in quality because of characteristics
such as gender, ethnicity, geographic location, and socioeconomic status chapter 10 ? Issues
of Quality and Safety 151 152 unit 3 ? Career Considerations standards of patient care
quality. This approach used retrospective chart audits and fixed errors after problems were
found. QA places very little empha- sis on change or assuming a proactive approach. In
contrast, QI infers a system-wide approach to maintaining quality. The Joint Commission
(2010) vision identifies the core of quality improvement as “All people should always
experience the safest, highest quality, best value health care across all set- tings” (para. 1).
QI usually involves the following common char- acteristics (McLaughlin & Kaluzny, 2006, p.
3): ? ? ? ? A link to key elements of the organization’s strategic plan A quality council
consisting of the institution’s top leadership Training programs for all levels of personnel
Mechanisms for s